Page 2

Details of person completing this record

  • Name (First & Last)

  • Are you a staff member?

  • Position/role

  • Date and time record was made

  • Signature

Child details

  • Child's name listed in title page section.

  • Age

  • Gender

Incident details

  • Centre location is in title page

  • Incident date

  • Name of witness (First & Last)

  • Witness Signature

Page 3

  • Type of incident

  • Time of onset of illness

  • What are the symptoms?

  • Please list symptoms

  • Any other additional information

  • STOP! Call HQ immediately on 0450 678 062

  • Have you called HQ?

  • Who did you speak to?

  • Was a child missing?

  • Who found the child?

  • How long was the child missing for? (answer is in minutes)

  • Any additional information

  • Remember DETAILS are important - who, what, when, where, how.

  • Circumstances leading up to the injury/incident (please include location if injury occurred at Inspire)

  • Cause of injury

  • Please select injury

  • STOP! Call HQ immediately on 0450 678 062

  • Have you called HQ?

  • Who did you speak to?

  • Photo of injury

  • Body part affected i.e. right knee

  • Remember DETAILS are important - what, when, where, how.

  • Where did this incident occur?

  • Circumstances leading up the incident

  • Cause of any injury?

  • Photo of injury/ body part affected

  • Remember DETAILS are important - who, what, when, where, how.

  • Please describe what happened prior and during the incident

Action Taken

  • Details of action taken (including first aid, administration of medication etc)

  • Did emergency services attend?

  • Was medical attention sought from a registered medical practitioner/ hospital?

  • What steps have been taken to minimise and prevent this type of incident in the future?

  • Additional notes

Page 4

Parent notification (including attempted notifications)

  • Parent/Guardian name (First & Last)

  • Date and time

Responsible Person notification

  • Responsible Person's name (First & Last)

  • Date and time

Other agency notification (if applicable)

  • Agency name

  • Name of person contacted

  • Date and time

Page 5

Parental acknowledgement

  • Name of Parent/Guardian (First & Last)

  • Date

  • Signature

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